Healthcare Provider Details

I. General information

NPI: 1174110324
Provider Name (Legal Business Name): ALEXANDRA NOVOA CF-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2020
Last Update Date: 12/22/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 GREENBRIAR DR
SOUTHLAKE TX
76092-8355
US

IV. Provider business mailing address

4609 BARNHILL LN
FORT WORTH TX
76135-2533
US

V. Phone/Fax

Practice location:
  • Phone: 817-442-9022
  • Fax:
Mailing address:
  • Phone: 817-962-7302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number117550
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: